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Spike In ER, Hospital Use Short-Lived After Calif. Medicaid Expansion

NPR Health Blog - Fri, 10/17/2014 - 2:02pm
Spike In ER, Hospital Use Short-Lived After Calif. Medicaid Expansion October 17, 2014 2:02 PM ET


One rationale for extending Medicaid coverage to more people is to help them get to a doctor or clinic before a minor illness becomes a medical emergency.


While the expansion of Medicaid under the Affordable Care Act may lead to a dramatic rise in emergency room use and hospitalizations for previously uninsured people, that increase seems to be largely temporary and should not lead to a dramatic impact on state budgets, according to an analysis from the UCLA Center for Health Policy Research released Wednesday.

Researchers reviewed two years of claims data from nearly 200,000 Californians, including patients who had enrolled in public health programs well in advance of last January's expansion of Medi-Cal, the state's version of Medicaid.

These programs were designed to ease the expansion of Medicaid by providing insurance to low-income adults who weren't eligible for Medi-Cal at that point but would be when the health law's expansion went into effect. The researchers divided the group into four categories, based on the researchers' assessment of each category's pent-up demand for health care.

“ What our findings say to the country is, concerns about Medicaid expansion being financially unsustainable into the future are unfounded.

In July 2011, after being enrolled in California's Low Income Health Program, the group with the highest pent-up demand had a rate of costly emergency room visits that was triple or more that of the other groups. But from 2011 to 2013, that high rate dropped by more than two-thirds and has remained "relatively constant," according to the analysis.

"We were hoping that this would be the case," says lead author Jerry Kominski, director of the UCLA Center for Health Policy Research, "because we think that, that's what access to care does for low-income individuals." Among people who haven't been able to afford to see a doctor, you see an additional increase in demand for services initially, he says. But "that demand, or utilization, drops off pretty rapidly."

Rates of hospitalization for the "highest pent-up demand" group also started high and dropped by almost 80 percent over the two-year period. Interestingly, you might think that as ER and hospitalization rates drop, outpatient visits might rise, as newly insured people who had been accustomed to heading to the ER for sore throats and rashes now consult their family doctor instead. But that wasn't the case; the rate of outpatient visits was largely unchanged during the two-year period.

Kominski says that one of the fears raised about the Medicaid expansion was the potential high cost of low-income patients. He thinks that this analysis should ease those fears.

"What our findings say to the country is, concerns about Medicaid expansion being financially unsustainable into the future are unfounded," he says. Under the Affordable Care Act, the federal government pays states 100 percent of the cost of the newly eligible under the Medicaid expansion, but in 2017 that contribution will phase down until it reaches 90 percent in 2020.

Twenty-seven states and the District of Columbia are implementing the Medicaid expansion; 21 have not, and in two states, Indiana and Utah, the question of expansion is an "open discussion," according to a tally from the Kaiser Family Foundation.

Matt Salo, executive director of the National Association of Medicaid Directors, says the study was "certainly consistent with what we hope to do" by expanding health insurance access. Insurance is "just the first step," he says. "The next step is health care homes so that the individual can actually get better care."

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One factor in helping drive down the higher rates of use, Kominski says, is better coordination for Medi-Cal beneficiaries. For example, virtually all Medi-Cal beneficiaries are now enrolled into a Medi-Cal managed care plan. "To the extent that other states don't have adequate coordinated care mechanisms in place for their Medicaid populations, then the kinds of drop-off that we observed in California may not occur there," Kominski said.

The UCLA analysis makes explicit reference to — and rebuts — a similar study, the Oregon Health Insurance Experiment. In Oregon in 2008, 10,000 residents literally won Medicaid coverage in a lottery, creating a true randomized controlled trial opportunity for researchers who compared those who won coverage with those who didn't. In the Oregon study, researchers reported a 40 percent increase in ER visits in the 18 months after that expansion.

Kate Baicker, a health economist at the Harvard School of Public Health, was one of the social scientists who analyed the Oregon experiment. She says her team did not find "any evidence of utilization tailing off over that 18-month window."

Still, Baicker says, an increase in the use of health care services, such as emergency room visits or hospitalizations, "does not mean that Medicaid should not be expanded; part of the goal is to increase access to health care."

The UCLA study was funded by the California Department of Health Care Services and Blue Shield of California Foundation.

This story is part of partnership that includes NPR, KQED, and the Kaiser Family Foundation.

Copyright 2014 KQED Public Media. To see more, visit
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Take Your Medicine, Tap Your Phone And Collect A Prize

NPR Health Blog - Fri, 10/17/2014 - 11:37am
Take Your Medicine, Tap Your Phone And Collect A Prize October 17, 201411:37 AM ET

A view of the rewards screen on the Mango Health app.

Meredith Rizzo/NPR

As a neurosurgeon in Connecticut, Dr. Katrina Firlik saw too many patients make the same mistakes, over and over again.

At her hospital in Greenwich she'd see patients with hemorrhagic strokes that could have been prevented. "They didn't take their hypertension medications for the last couple decades," she says.

A new tool from HealthPrize syncs with your smartphone to let the company know when you've taken your medication so you can reap your rewards.


Firlik wanted to try to stop these problems. In 2009, she co-founded the company HealthPrize with two other health care entrepreneurs, Tom Kottler and James Jorasch, to create an app that would motivate people to take their meds.

HealthPrize offers reward points, much like Candy Crush or Fruit Ninja, to get people to stick with their prescriptions.

The company has recently partnered with West Pharmaceutical Services, a company that makes specialized devices for drugs that are injected, such as insulin. The customized tools ping a patient's smartphone when a drug has been injected. HealthPrize tracks the pings to verify that people have taken their medicines.

Patients who don't take their medicines, as Firlik saw, are at risk for strokes, heart attacks, blood clots and even death. The failure to follow through on doctors' prescriptions leads to problems that cost the U.S. health care system more than $290 billion a year, according to a report conducted by the New England Healthcare Institute. The costs include additional hospital admissions and extra emergency room visits.

The reasons patients don't take their drugs range from unwillingness to fork over a copay to worries about side effects. Another reason is that many chronic conditions, such as high blood pressure, don't have symptoms. And unlike an antibiotic or painkiller, the drugs people take to control many chronic conditions don't make them feel better.

Cholesterol-lowering statins are among the most-prescribed drugs in the U.S., but about 50 percent of patients don't take them as they should. "The No. 1 reason people don't take statins is because they don't really believe they need them," says Josh Benner, founder of RxAnte, a company that consults health groups on what types of patients don't take their medications. People don't think they're going to get a heart attack or a stroke, so they pass on the pills.

That's why startups like HealthPrize and Mango Health use rewards to make taking medicines part of a larger game to give people a boost of motivation.

Running through HealthPrize's blood are ties to Priceline and research in consumer motivation, casinos and gaming. "We understand consumers when it comes to Las Vegas, vending machines, lottery tickets," says Firlik.

Similarly, Mango Health's brightly colored fruit logo and friendly mobile interface sprang from the minds of former gaming industry executives. It makes sense to use a gaming angle to get you to take your meds, says Jason Oberfest, the CEO of Mango Health, because "our [demographic] looks very similar to mobile games."

He describes the average user of the Mango Health app as a woman, early to mid-50s, who enjoys Instagram and uses mobile banking apps. She would like a simple app on her phone to help her manage her recently diagnosed condition and the drugs her doctor told her she needs to start taking.

HealthPrize and Mango Health partner with health care groups, such as pharmaceutical companies, health insurance companies or physicians, to offer specific incentives for medical conditions and associated prescriptions. They verify that patients are refilling their prescriptions through the drug companies or pharmacies, while patients enter data on an app or mobile website, saying they took their medication.

Patients who take their medicines can collect various rewards, including gift cards to Amazon or Starbucks, cookbooks or donations to their favorite charities. "It's the immediacy of the reward that's critical," says Firlik. For HealthPrize, "the most common items that are redeemed are for $5 or $10 gift cards."

Depending on the app, the bill for the rewards is footed by a pharmaceutical company (HealthPrize) or the company itself (Mango Health).

In a study of 300 patients using HealthPrize over 20 months, they were, on average, 54 percent more likely to take their blood pressure medication than patients taking the same drugs but not in the program, according to the company.

In a study of 7,800 patients taking an acne prescription, those using HealthPrize refilled their prescription nearly three times as much as those not using it. Mango Health's first six months of data indicate that the rates of patients taking their medication with Mango Health are 20 to 25 percent higher than those not enrolled in the program.

However, neither HealthPrize nor Mango Health has published peer-reviewed studies, which leaves some cautious of the claims. "It's hard for me to imagine the apps overcoming understanding the need for treatment or fear of side effects," says Benner. "Those are, in our experience, best addressed by health care professionals."

However, Benner says he hopes the companies will sharpen their focus on people who could get help from apps. "They're just not going to be appropriate or effective for everybody," he says. But for those experiencing their first long-term everyday pill, an app could provide just the kick they need.

Copyright 2014 NPR. To see more, visit
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Just Seeing Charts And Graphs Makes Drug Claims More Credible

NPR Health Blog - Fri, 10/17/2014 - 8:02am
Just Seeing Charts And Graphs Makes Drug Claims More Credible October 17, 2014 8:02 AM ET

When people see charts like this, they think the drug is more effective than if they just read about the data, a study finds.

Source: Cornell University

Graphs and formulas say "Science!" to consumers, so much so that simply seeing claims about a new drug that were accompanied by data visualizations made people more likely to believe the claims.

The effect is especially true if people have a strong belief in science to begin with.

That's the conclusion of a study published online in the journal Public Understanding of Science. It includes three experiments. In the first, 61 people read a paragraph saying that a nonexistent new drug enhances immune function and reduces the likelihood of catching a cold by 40 percent. Half of the people also saw a graph that repeated the numbers but contained no new information.

Of those who saw the text and the graph, 97 percent said they believed the drug worked, compared with 68 percent for the people who saw only the text.

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The researchers, from the Cornell Food and Brand Lab, wanted to be sure that difference wasn't just because one group had the information repeated for them in graph form. So a separate group of 56 people saw the text and the graph, or the text plus an extra sentence repeating some of the information.

Again, the people who saw the graph rated the medication as more effective – especially those who said they believed in science.

Finally, the researchers wanted to make sure that the effect didn't just hold for visual representations of information such as a graph.

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So a different group of 57 people received information about another hypothetical drug. For half, that included the drug's chemical formula. Those who saw the formula believed the drug would work two hours longer than those who didn't get the formula.

Even "trivial elements that are associated with science ... can enhance persuasion," the authors said. That's important in an era of sometimes-dubious health claims for foods and supplements as well as medications. Indeed, a Nielsen survey a few years back found that while most people say they don't believe the claims on food labels, they were more likely to believe claims backed by numbers.

Cornell behavioral economist Aner Tal, an author of the study, says there's nothing inherently illegitimate about product information, marketing materials or advertisements that include graphs or formulas. It's just that those elements make the marketing message more convincing. So he warns that it's important to consider the source of all that information, no matter the form it takes. Is it from the company itself or a source funded by the company? Or is it from an independent source?

He says it can't hurt to approach "science-y" information like graphs or formulas with a more critical attitude. But he doesn't know if putting your guard up can make you immune to the bias.

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Women Can Freeze Their Eggs For The Future, But At A Cost

NPR Health Blog - Thu, 10/16/2014 - 5:19pm
Women Can Freeze Their Eggs For The Future, But At A Cost October 16, 2014 5:19 PM ET Listen to the Story 4 min 6 sec  

A doctor uses a microscrope to view a human egg during in vitro fertilization (IVF), which is used to fertilize eggs that have been frozen.

Mauro Fermariello/ScienceSource

Until recently, freezing a woman's eggs was reserved mainly for young women facing infertility as a result of cancer treatments like chemotherapy.

But recent advances in technology have made freezing eggs easier and more successful, and likely have a lot to do with the recent decisions by Facebook and Apple to offer female employees a health benefit worth up to $20,000 to freeze their eggs.

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The benefit is intended for women who don't need to freeze eggs for medical reasons, but rather as a choice. This would likely appeal to women who want to focus on their careers instead of child rearing, as well as women who just haven't yet met "Mr. Right."

Doctors have had the technology since the mid-1980s. But, according to Dr. Richard Paulson, director of the fertility program at the University of Southern California, it just didn't work very well. "Everybody figured there was something wrong with the eggs after freezing them; you just couldn't get them to fertilize," he says. Then, about 10 years ago, someone came up with the smart idea to use technology typically used to help weak sperm fertilize an egg.

No Longer Experimental, Egg Freezing May Appeal To More Women

"I think it would be fair to say the 'ah-ha' moment came when someone figured out that you could bypass the hardened egg shell," he says.

When eggs are frozen, their "shells" harden. Researchers bypassed the hardened shells by injecting sperm through the shell and directly into the egg. Then, within a few years, a rapid new freezing method enabled eggs to be quickly frozen with their quality preserved, putting the eggs into a "state of suspended animation," says Paulson.

Even so, age remains a major caution. Since eggs degenerate with age, the younger a woman is when she freezes her eggs, the better. For example, if a 30-year-old freezes her eggs and then uses them at age 38 or 40, she will be getting pregnant with the eggs of a 30-year-old with lower risk of miscarriage and genetic defects, including Down syndrome.

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Egg freezing doesn't stop the biological clock, says Paulson. It just sort of "pauses it," he says, giving women the option to delay childbearing until they're ready.

While egg freezing is "an exciting new option," it shouldn't be relied on to make family-planning decisions, says Dr. Valerie Baker, a fertility specialist at Stanford University Medical Center. "We wouldn't want to have people think this is a substitute for making family building decisions in a broader context. It's not a guarantee that if a woman freezes her eggs she's eventually going to be able to have a baby with one of those eggs."

Baker says it's more reliable for women to try to get pregnant at a younger age, if possible, rather than banking eggs and hoping to get pregnant later in life. Even so, in vitro fertilization, or IVF, either with fresh or frozen eggs certainly boosts a woman's chance of getting pregnant at any age.

But egg freezing is costly, both emotionally and financially. Many women will have to undergo the procedure more than once. It cost about $10,000 to harvest eggs from the ovaries, after a woman has taken medications for several weeks to stimulate egg production. Then the eggs need to be frozen and stored, at a cost of about $500 a year. Each time eggs are thawed, fertilized and transferred to the uterus with IVF it costs about $5,000.

Baker adds another caution: Not all women have the same biological clock. "Some women are running out of eggs when they're in their late 20s/early 30s, whereas other women may have reasonably good fertility into their mid- to late 30s," she says. Reproductive specialists can help women figure out which category they are in, which is an important factor to consider when thinking about freezing eggs.

Most insurance companies don't cover the cost of egg freezing, not even for medical reasons when a young woman's fertility is jeopardized by cancer. So the decision by Facebook and Apple to foot the bill is a significant benefit for women who want to freeze their eggs.

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